effect of combination of bortezomib/dexamethasone/zoledronic acid on bone disease in patients with multiple myeloma relapsed after 1-3 prior lines of therapy

Conditions: Multiple Myeloma

Summary: the aim of this study is to evaluate the effect of bortezomib in combination with dexamethasone and zoledronic acid on bone mineral density (bmd) and skeletal related events (sres) in patients with multiple myeloma who have relapsed after 1-3 prior lines of therapy

multiple myeloma represents a malignant proliferation of plasma cells derived from a single clone. the most common symptom in myeloma, affecting more than 70% of patients at diagnosis, is bone pain. the pain usually involves the back and ribs, and is precipitated by movement. bone fractures are commonly seen in myeloma patients and may present with persistent localized pain. velcade (bortezomib) is a proteasome inhibitor used for the treatment of multiple myeloma. velcade seems to be the first agent to combine significant anti-myeloma activity and beneficial effects on bone remodeling. thus, it appears to be a very promising tool for the treatment of myeloma patients. in this study, a regimen consisting of bortezomib/dexamethasone/zoledronic acid will be used. the rationale for using this regimen is that: * velcade (bortezomib) is indicated for the treatment of relapsed myeloma patients participating in the study and it has also a beneficial effect on biochemical markers of bone formation. * in phase ii studies, the addition of dexamethasone in patients with a suboptimal response to bortezomib alone improved efficacy in relapsed or refractory multiple myeloma patients, without increasing adverse events. therefore, in this study, the addition of dexamethasone aims at providing the optimal therapy for participating myeloma patients. * zoledronic acid, the most potent i.v. bisphosphonate, is used because of its established effect on reducing skeletal related events in patients with multiple myeloma due to its inhibitory effect on osteoclastic bone resorption. dosages and timing of dosages are based on current recommendations and guidelines for the treatment of myeloma patients who have relapsed after 1-3 prior lines of therapy.

Eligibility criteria:
inclusion criteria: * patients with multiple myeloma who have relapsed after 1-3 prior lines of therapy * women \> 50 years old * κarnofsky performance status ≥ 60 (patients with lower performance status due to myeloma bone disease can also be included) * measurable disease * platelet count \>50x10(9)/l * neutrophil count \>0.75x10(9)/l * hemoglobin ≥7.0 g/dl (the use of recombinant human erythropoietin or red blood hell transfusions to maintain hemoglobin levels above 7.0 g/dl is not an exclusion criterion) * serum alt and ast ≤ 3-fold of upper normal limit * serum bilirubin ≤ 2-fold of upper normal limit * serum calcium ≤ 10.5 mg/dl * expected survival ≥ 2 months * signed informed consent exclusion criteria: * presence of another cancer * serious medical or psychiatric illness likely to interfere with participation in this clinical study * grade 2-4 peripheral neuropathy or neuropathic pain grade 2 or higher as defined by nci ctcae version 3 * pregnant women \> 50 years old or breast-feeding * woman \> 50 years old capable of becoming pregnant \[anyone who has not undergone a hysterectomy, has not had both ovaries removed or has not been post-menopausal for more than 24 months in a row not using adequate contraception * known or suspected hypersensitivity or intolerance to bortezomib, boron, mannitol, zoledronic acid, dexamethasone, or heparin (if an indwelling catheter is used) * uncontrolled diabetes (if receiving antidiabetic agents, subjects must be on a stable dose for at least 3 months prior to first dose of study drug) * uncontrolled or severe cardiovascular disease including myocardial infarction within 6 months of enrolment, new york heart association (nyha) class iii or iv heart failure (attachment 4, nyha classification of cardiac disease), uncontrolled angina, pericardial disease, or cardiac amyloidosis * acute diffuse infiltrative pulmonary disease * history of hypotension or patient has decreased blood pressure (sitting systolic blood pressure \[sbp\] 100 mmhg and/or sitting diastolic blood pressure \[dbp\] 60 mmhg) * patient has received extensive radiation therapy, systemic chemotherapy, or other antineoplastic therapy within 4 weeks prior to enrolment * patient has received any drugs or agents that inhibit (e.g., cimetidine, erythromycin, fluoxetine, ketoconazole, paroxetine) or induce (e.g., carbamazepine, glucocorticoids, phenobarbital, rifampin) cyp2c19 or cyp3a4 within 14 days before the first dose of velcade (proton pump inhibitors are allowed) * need for therapy with concomitant cyp 3a4 inhibitors (e.g., itraconazole, fluconazole, clarithromycin, erythromycin, norfloxacin, fluvoxamine, cimetidine, indinavir, ritonavir) or inducers (e.g., efavirenz, barbiturates, phenytoin, rifampin, glitazones). proton pump inhibitors are allowed. * patient has received an experimental drug or has used an experimental medical device within 4 weeks prior to the planned start of treatment. concurrent participation in non-treatment studies is allowed, provided it will not interfere with participation in this study.

Keywords: multiple myeloma 1-3 prior lines of therapy bortezomib (velcade) zoledronic acid (zometa) dexamethasone bone mineral density bone pain bone metabolism osteolytic lesions dexa-scans x-ray radiography